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To alleviate blame and shame and build an alliance with the family, I then discussed the current understanding of OCD as a neurobehavioral disorder. "Having OCD isn't your fault. It's not your parents' fault either. It's like having allergies or asthma—it happens to you because you're more sensitive to it. Sometimes there are other people in your family who are also sensitive and have OCD. OCD isn't something you do on purpose to get attention or because you're lazy. Sometimes your parents or your teachers or friends may think that you're just being stubborn or annoying. It's hard for them to understand that you don't want to do it, but you don't know how to stop." Maria glanced at her parents with a "See, I told you!" look, as her mother tearfully acknowledged having had such reactions.

Communication is key. Most children and families aren't aware that the body is designed to habituate naturally to anxiety. I developed the Worry Hill metaphor to make CBT more child-friendly and prepare children for treatment, by helping them understand how exposure leads to habituation. It's a drawing of a bell-shaped curve that graphically illustrates how anxiety rises with exposure until it reaches a peak, and then, if the child persists in resisting the urge to employ the usual anxiety-avoidance tactics, automatically begins to decline.

In our second session the next week, I explained to Maria and her parents, "Learning how to stop OCD is like riding your bicycle up and down a hill. At first, facing your fears and not doing your rituals feels like riding up a big Worry Hill, because it's tough. You have to work hard to huff and puff up a hill, but if you keep going, you can get to the top. Once you get to the top, it's easy and fun to coast down the hill.

From Psychotherapy Networker, May/June 2008

Sample from: The Healing Power of Play, by David Crenshaw

In the fourth session, we continued with these playful activities—dropping in and springing out of the water—repeated many times with the jungle animals, farm animals, dogs, and the figures of adults and children. All of them were jumping into and out of the water, obviously having a good time. Bobby's parents' active participation in the play therapy intervention was crucial because they, too, were "shell-shocked" by this horrific experience of almost losing their son, their only child, and had no idea how to help him. Engaging in the play activities with Bobby was empowering for them and for him.

A clear indication that Bobby was healing was his increasing ability to play again, both in the session and at home. He entered the play in each subsequent session with more gusto, even at times with screams of delight. This was particularly significant because the trauma event occurred while Bobby was running around in the backyard playing. Meanwhile, at home, he was recovering his language ability, was less fretful, and usually slept through the night, much to his parents' relief.

But there was one more major step left to accomplish: we needed to "bracket" the event for Bobby—make it clear that what he'd experienced was extremely unlikely to occur again. Even adult trauma survivors often find their assumptions of safety in the world so shattered that they need help placing traumatic events in a meaningful context, so they can realize emotionally that the trauma will not endlessly recur. Children have less ability to put traumatic events into perspective and understand that what happened was a rare, improbable event that won't need to be confronted over and over again. This bracketing of the trauma event was a challenge with a child as young as Bobby.